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Diagnosis (Berl). 2017 Jun 27;4(2):79-86. doi: 10.1515/dx-2017-0013.

Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system.

Author information

1
University of British Columbia, Program Office for Laboratory Quality Management, Vancouver, BC, Canada.
2
British Columbia Patient Safety and Learning System, Vancouver, BC, Canada.

Abstract

BACKGROUND:

This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System.

METHODS:

The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported.

RESULTS:

Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences.

CONCLUSIONS:

It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.

KEYWORDS:

laboratory error; patient safety; post-analytical; pre-analytical; quality; reporting system

PMID:
29536919
DOI:
10.1515/dx-2017-0013
[Indexed for MEDLINE]

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